Project Summary/Abstract The sickest patients should receive priority access for organ transplant to avoid dying on the waitlist. However, while high acuity patients comprise 10% of the U.S. lung transplant waitlist, they account for 60% of lung transplant waitlist deaths. There are 59 Donor Service Areas (DSAs) in the U.S. whose boundaries were created in 1984 based on the preferences of the few early transplant centers. Over the years, these boundaries have created a system where 81% of donor lungs allocated within a DSA are to low acuity patients even when a matched higher acuity patient exists just outside the boundaries in a separate DSA, resulting in an avoidable waitlist death. This grant is premised on the notion that these geographic boundaries are an artificial allocation criterion limiting access of high priority patients to lung transplant. It further serves as a response to a U.S. government mandate to identify solutions to minimize the role of geography in organ allocation. The long-term goal is to systematically address disparities in organ allocation; an example of which is the geographic disparity in access to lung transplant. Evidence suggests that broader geographic sharing of other solid organs can reduce avoidable waitlist deaths, however the role of broader sharing in lung allocation remains to be elucidated. The central hypothesis is that broader geographic sharing of donor lungs will reduce avoidable waitlist deaths. This hypothesis will be tested through two independent specific aims: (1) Compare the effect of waitlisting patients in multiple DSAs vs one DSA on avoidable waitlist deaths. (2) Compare the effect of sharing donor lungs beyond current DSA boundaries on avoidable waitlist deaths. This grant will also assess the impact of travel costs on patients and transplant centers which may be a barrier to policy implementation. The proposed research is significant because it could reduce avoidable waitlist deaths and have applications to other solid organ transplants. The proposal is innovative because it is the first to apply known methodologies in economic modeling to organ allocation to better understand the impact of policy changes on patients and transplant centers. This research will be performed under the mentorship of Dr. Raed Dweik, who has extensive experience mentoring K awardees and serves as director of the city-wide, multidisciplinary KL2 Scholars Program. A mentoring committee which combines transplant expertise and a track record of guiding scientists towards R01 independence (Drs. Blackstone, Erzurum, Palmer, and Valapour) has helped create a career development plan that will build towards a successful PhD degree. The objective is to gain skills that will build on the well- established skillset of the mentors and collaborators which can only be earned through further education during this early career phase. This application emphasizes a commitment to patient-oriented research, strong mentorship, and the dedication of the Cleveland Clinic to training the next generation of independent R01 funded physician scientists.